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Monitoring illicit psychostimulants and related health issues
Brunt, T.M.
Publication date
2012
Link to publication
Citation for published version (APA):
Brunt, T. M. (2012). Monitoring illicit psychostimulants and related health issues. Boxpress.
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Chapter 4
An analysis of cocaine powder in The
Netherlands: content and health
hazards due to adulterants
Tibor M. Brunt, Sander Rigter, Jani Hoek, Neeltje Vogels,
Peter van Dijk and Raymond J.M. Niesink
Based on:
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Abstract
Aims To report on trends in the content and adulterants present in street
cocaine (powder) in The Netherlands and to describe the associated hazards to the health present. Design and participants. Drug consumers handed in samples of cocaine powder during 1999 to 2007 for analysis. Reports were compiled of users‟ experiences with the samples received.
Measurements and analysis. Linear regression analysis was used to
assess the trend in adulterated cocaine powder across the study period, and comparison of reported adverse effects of adulterated with those of unadulterated cocaine by Fischer exact test. Findings. There was a statistically significant upward trend in the occurrence of adulterated cocaine powder over the years. Adulterated cocaine was more frequently associated with reported adverse effects than unadulterated cocaine. Phenacetin, hydroxyzine and diltiazem appeared to be three adulterants contributing to these adverse effects. Conclusions. An increase in adulterants was detected in the analysed cocaine powder between 1999 to 2007. This increase is associated with relatively more adverse effects with cocaine use. The cardiac and hallucinatory effects that were reported more frequently are not understood clearly. Adverse effects are likely to be due to several factors, including interactions of adulterants with cocaine and the route of administration.
Introduction
Cocaine is associated with various toxic effects on the human body, especially on the cardiovascular system (Lange & Hillis, 2001;Pozner, Levine, & Zane; 2005). On occasions, cocaine can cause ischemia and infarctions within a few hours after ingestion. This may result in hospitalization or even sudden death in both initiators and regular cocaine users (Frishman, Del Vecchio, Sanal, & Ismail; 2003). Cocaine may also cause cerebrovascular effects resulting in cerebral ischemia and stroke (Buttner, Mall, Penning, Sachs, & Weis; 2003). Several studies have also reported rhabdomyolysis (breakdown of skeletal muscles) after high dose
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cocaine use, subsequently leading to renal failure (Horowitz, Panacek, & Jourisles, 1997; Nolte, 1991). Many of these latter effects typically occur after chronic and heavy use.
Cocaine is one of the most widespread used drugs worldwide (UNODC; 2007). The overall prevalence of cocaine use in the total adult population in Europe is 3.7%, with at least 12 million Europeans having used this drug in their lifetime (EMCDDA; 2007). The number of cocaine users has steadily increased from 1992 until 2005 (UNODC; 2007). It is estimated that current cocaine use (last month) in Europe is twice that for MDMA (ecstasy). Intranasal ingestion (snorting) of cocaine hydrochloride is the most common administration route among powder users; smoking or “basing” cocaine is restricted to a relatively small group of problematic and marginalized users (van Laar, Crutz, Verdurmen, van Ooyen-Houben, & Meijer, 2008).
Although several laboratory studies have described the effects of cocaine on the body and nature of cocaine dependence (Foltin, Fischman, & Levin, 1995; Epstein, Preston, Steward & Shaham, 2006), street cocaine usually differs considerably from the pharmaceutical grade cocaine which is used under laboratory conditions (EMCDDA; 2007; Foltin, Fischman, & Levin; 1995). However, adverse reactions and other serious health hazards may occur, when a drug turns out to contain another pharmacologically active component (adulterant). The Dutch Drugs Information and Monitoring System (DIMS) monitors the contents of cocaine hydrochloride powder (cocaine herein) sold on the street and also records users‟ experiences of the drug‟s effects.
Previous research has identified caffeine, lidocaine, benzocaine, diltiazem, procaine and phenacetin as adulterants in cocaine samples (McKinney, Postiglione & Herold; 1992; Fucci & De Giovanni; 1998; Kenyon, Ramsey, Lee, Johnston & Holt; 2005; Staack, Paul, Schmid, Roider & Rolf; 2007). More recently, also hydroxyzine and levamisole were identified in seized illicit cocaine shipments (Fucci; 2007; Behrman; 2008); and in one case, poisoning with cocaine adulterated with atropine was described (Weiner, Bayer, McKay, DeMeo & Starr; 1998). Lidocaine, procaine and benzocaine are all common local anaesthetics (Sweetman; 2006). The other described
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adulterants are prescription medicines with various applications: diltiazem is used in cases of cardiac arrhythmias or ischemia (Apostolakos & Varon; 1996); phenacetin has been used as analgesic (Sweetman; 2006), but it has been removed from the pharmaceutical market because of renal toxicity and alleged carcinogenicity (Ames, Magaw & Gold; 1987); atropine is also indicated for multiple clinical purposes, such as toxicity by nerve agents or eye surgery (Geyermek; 1998); levamisole is used as anthelmintic (medicines used to expel parasitic worms) and as adjuvant in malignant disease (Sweetman; 2006). Adverse effects to most of these substances are well described (see Table 1).
Using DIMS monitoring data, this report describes the contents of street cocaine powder and possible additive health hazards posed by the adulterants present. Data from users‟ self-reports are used to contrast experienced adverse effects of adulterated cocaine with unadulterated cocaine.
Table 1. Adverse pharmacotoxic effects of known adulterants.
Adulterants Main usea Possible adverse effectsa
Lidocaine Local anaesthetic Central nervous: nausea, vomiting,
dizziness, tremors, convulsions. Cardiovascular: myocardial depression, hypotension, bradycardia, arrhythmias.
Procaine Local anaesthetic As lidocaine (see above).
Benzocaine Local anaesthetic As lidocaine (see above). Also,
methemoglobinemia is associated with large doses.
Phenacetin Analgesic Chronic use associated with
nephrotoxicity leading to incontinence and back and flank pain.
Caffeine CNS stimulant Chronic use associated with
withdrawal symptoms, including headache, irritability.
88 Hydroxyzine Sedative, anxiolytic. Also used as antihistamine. Dizziness.
Levamisole Anthelmintic and
adjuvant in
malignant disease.
After acute intake: nausea, diarrhoea and dizziness.
After prolonged intake: muscle pain, headache, fever, insomnia, dizziness and convulsions.
Diltiazem Calcium channel
blocker. Used in cardiovascular disease.
Adverse cardiovascular reactions, including angina, bradycardia, hypotension and arrhythmia may occur. Also fainting, nausea, vomiting and diarrhoea. Atropine Antimuscarinic agent. Various clinical applications: treatment of brachycardia, inducing mydriasis in eye surgery.b
Central nervous: amnesia,
disorientation, visual hallucinations, ataxia, psychoses and eventually coma.
Peripheral: tachycardia, mydriasis, restlessness, urinary retention,
disturbed speech and swallowing. b
Methods
The DIMS network
DIMS is a large network of institutions for mental health and addiction care within The Netherlands. The coordinating and steering centre is at the Netherlands Institute of Mental Health and Addiction in Utrecht. The participating institutes are located throughout the country and they offer a laboratory drug testing service to individuals who wish to evaluate the content of street drugs in their possession. Drug users hand in their drugs anonymously and they are invited to report their experiences with the drugs they hand in, if any. Personnel working in these offices are trained in providing information on drugs and the feedback of laboratory results to the
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individual consumers. Centrally, information about drugs is compiled in a database and laboratory results are reported via a secure website which is only available to those participating in the DIMS system.
An important record in the DIMS database is the user‟s report on what information was given at the time of purchase concerning the nature of the product (i.e. in the present context, DIMS can report on whether what was sold as cocaine does indeed contain cocaine as the main active ingredient). This is important information from a public health perspective. Through laboratory analysis, potentially dangerous substances are identified and communicated throughout the DIMS network. In this fashion, information is quickly gathered and appropriate measures can be undertaken, such as warning campaigns (Keijser, Bossong & Waarlo, 2007; Spruit; 2001). Additionally, DIMS has a surveillance function and reports on trends and new substances in the street drug market.
Drug testing
The DIMS testing function is conducted by various testing offices. Drug consumers hand in their drugs and receive the laboratory results one week later. Because of this weekly update of information on drugs with various appearances, test offices can sometimes recognize certain drugs on the spot through the database on the DIMS website. This mainly applies to tablets, capsules and squares of paper presumed to contain hallucinogens. A number of main psychoactive ingredients in powder samples are established through the Marquis reagent test (Jeffrey; 2003). For example, this reaction will turn colourless/pink if the drug contains cocaine.
Cutting agents and adulterants
The term cutting agent is often used synonymously with adulterants in the scientific literature. In both cases, the substances may be used to increase profit by diluting the pure cocaine with cheaper alternatives. However, while cutting agents refer to pharmacologically inactive substances with a similar appearance as cocaine (e.g. sugars such as inositol and mannitol),
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adulterants are pharmacologically active substances which may modify the characteristics of cocaine. Topical anaesthetics may be used to create the same oral numbness that pure cocaine causes, so the customer will get the impression of high-quality cocaine whereas in actuality, the user is receiving a diluted product. In this article, only adulterants will be discussed.
Laboratory analysis
The laboratory analysis for DIMS proceeds as follows: samples are first crushed and homogenized, then Thin Layer Chromatography (TLC) is used
for identification (using the ToxiLab®A procedure). The analytes are
identified by relating their position (RF) and colour to standards through four stages of detection. Cocaine is typically identified with RF 0.78. To confirm TLC results, the sample is determined using a gas chromatography nitrogen phosphorous detection (GC-NPD) procedure (Interscience GC8000/NP-800). A solution is prepared using an internal standard (Chirald). Cold on column injection is then used, with a temperature program detector temperature 300 °C and with Nitrogen-Phosphor-Detector and Helium as the carrier gas. In the case of a discrepancy between these two methods of analysis, identification with gas chromatography-mass spectrometry (MS) was used (the GC-conditions are similar to GC-NPD). The NIST(National Institute of Standards and Technology)-library is then used to identify the various mass fragments. This procedure is optimized for detecting pharmacological active compounds, such as medicines or illicit drugs.
Data analysis
The distribution of reported adverse effects between adulterated and unadulterated cocaine by drug users, and the associations between different adulterants and reported adverse effects were analyzed by Fischer‟s exact test. Trend in the adulteration of cocaine over the years was determined with linear regression analysis. SPSS version 15.0 was used for all statistics (SPSS Inc, Chicago, Ill).
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Results
A total of 3230 samples of powder sold as cocaine were handed in for analysis by DIMS between 1999 and 2007. Some 2824 (87.4%) contained cocaine. These samples were used for the analysis of adverse effects, since the comparison could be made between cocaine with or without adulterants. The 406 samples that did not contain cocaine as component were taken to be false samples.
Trends in the content of cocaine powders
Trends in the content of powder sold on the street as cocaine during 1999 and 2007 are show in Figure 1. Only a small proportion of the samples sold as cocaine actually contained another component that was not cocaine. They consisted of either no pharmacological active components whatsoever (such as sugars), or other pharmacological active components than cocaine, such as amphetamine or caffeine. There is a clear trend for more detected adulterants in the cocaine samples tested over time. Regression analysis shows a significant trend by year from 1999 to 2007 (6.6% annual increase (95% confidence interval, 5.9-7.3%), P<0.001). Whereas in 1999 the proportion of adulterated cocaine was 6.5%, this increased to 57% in 2007.
Over the years the diversity of adulterants found in cocaine has increased considerably. The percentages of the most frequent types are shown in Table 2. Mainly, phenacetin seems to be a preferred adulterant in cocaine throughout the years. But other adulterants likewise appear more frequently, such as procaine, caffeine and novel adulterants such as diltiazem and levamisole. By contrast, the presence of the local anaesthetic lidocaine is declining over the years. Rather than percentages, the absolute numbers (n) of samples containing atropine are given in Table 2 to illustrate the contrast between adulterants with acute and secondary health hazards. In 2004, atropine appeared on the Dutch cocaine market, which was a reason to alert the authorities and orchestrate a national mass media warning campaign. Atropine is very toxic at low doses and in combination with cocaine life-threatening situations may occur. This
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situation repeated itself in 2005 and 2007 when again several cocaine samples were identified containing atropine.
Reported adverse effects of cocaine powders by drug users
The reported effects were interpreted from a perspective of physiological or psychological health as either adverse or not. Of the 2824 users that handed in their cocaine samples, 172 reported adverse effects and 487 reported otherwise (for instance pleasant or non-specific effects). The remainder did not report anything. The reported adverse effects varied in seriousness from nausea to cardiac effects; in some instances resulting in emergency care hospitalization. A subdivision into the categories of these adverse effects is shown in Table 3.
93 Figure 1 . Trend s in pow de rs sol d as co cai ne , su bd ivi de d in to fou r c ate go ries: po w de rs con tai ni ng un ad ul terat ed coca ine , ad ul tera ted coca ine , othe r ph ar m aco log ical ly activ e su bstances an d po w de rs con tai ni ng no ph arm aco lo gi cal ly activ e sub st an ces. 0% 20 % 40 % 60 % 80 % 10 0% ye ar ( n =) % o f o th er p ha rm . a ct ive s ub st an ce s 4. 1 7. 3 7. 4 6. 7 3. 1 6. 1 5. 2 3. 3 3. 5 % o f n o ph ar m . a ct ive s ub st an ce s 7. 4 8. 0 4. 3 3. 6 1. 8 2. 4 2. 7 2. 4 3. 0 % o f a du lte ra te d co ca in e 6. 5 17 .0 18 .5 14 .9 25 .0 39 .5 41 .2 55 .7 53 .6 % o f u na du lte ra te d co ca in e 82 .0 67 .7 69 .8 74 .8 70 .1 52 .0 50 .9 38 .6 39 .9 19 99 (1 22 ) 20 00 (1 35 ) 20 01 (1 65 ) 20 02 (2 02 ) 20 03 (2 28 ) 20 04 (3 75 ) 20 05 (6 38 ) 20 06 (6 30 ) 20 07 (7 35 ) 93
94 TA B LE 2. Adu lterant s th at w ere fou nd in coca ine po w de rs in pe rcen tag es . O ne or m or e ad ul teran ts can be present in on e pow de r. Yea r (n=) Adu lterant s 19 99 (10 8) % 20 00 (80 ) % 20 01 (14 3) % 20 02 (17 5) % 20 03 (21 7) % 20 04 (34 3) % 20 05 (58 8) % 20 06 (59 3) % 20 07 (68 3) % P he na cetin 1.6 1.3 2.1 7.4 16 .8 35 .6 38 .3 48 .0 40 .6 Li do cai ne 3.8 15 .0 14 .0 8.7 8.3 5.2 4.8 8.2 6.4 P roca ine 1.0 5.0 2.8 1.7 3.7 4.8 3.4 12 .0 8.3 B en zoca ine -1.0 0.5 0.5 0.2 C aff ei ne 4.0 2.5 5.6 4.6 3.7 5.5 7.8 10 .9 15 .8 H ydroxy zi ne -1.0 0.5 2.0 4.4 D ilt ia zem -1.0 2.0 6.6 12 .0 Le vamiso le -0.6 1.0 4.5 11 .6 n n n n n n n n n A trop ine # -3 3 -7 # At rop ine is no t g iv en in pe rcen ta ges , bu t ab sol ut e num be r o f sa m pl es. T hi s sub st an ce is acu tel y to xi c an d w arni ng campai gns w ere im m ed ia tel y ini tiated w hen thi s sub st an ce w as e nco un tered in cocai ne sa m pl es. 94
95 Tab le 3. R ep ort ed ad verse ef fects in coca ine p ow de rs an d the ir asso ci atio ns w ith the m ai n ad ul terant s ar e gi ven in C hi -sq ua re v al ue s. A dv erse ef fec ts are sub di vi de d in fi ve m aj or ca te gorie s. C atego ries A dve rse e ffec ts All N au sea H ea da che C ardi ac ef fec ts A llergi c rea ct ion s H al luci -na tion s Freq ue nc y 34 36 54 16 34 Adu lterant s A ll
5.4* 4.3 0.4 10 .8** 0.0 4.0 P he na cetin 99 6 7.7* * 1.3 2.4 7.7* * 0.0 4.8* Li do cai ne 24 8 0.2 1.2 0.3 1.4 0.4 2.02 P roca ine 19 5 3.0 0.0 1.4 2.1 1.1 1.68 C aff ei ne 30 9 1.1 0.1 0.6 4.3 1.8 0.1 H ydroxy zi ne 47 4.9* 0.5 0.4 0.1 2.4 12 .0* D ilt ia zem 13 7 10 .6** 0.2 0.2 9.3* * 0.1 14 .0** Le vamiso le 11 5 3.8 0.1 0.1 2.9 0.6 2.5 Associ atio ns w ere de te rm ine d usi ng the Fi sche r‟s ex act test . S ig ni fican ce is sho w n as * P < 0. 05 . * * P < 0. 01 . 95
96
Distribution of the adverse effects was compared between adulterated and unadulterated cocaine samples. Benzocaine and atropine were not included in this comparison, since the percentages were too low for reliable statistical analysis. Reports of adverse effects were more likely when adulterated cocaine was taken than unadulterated cocaine, as can be seen
in Table 3 ( 2=5.4, P=0.02). Phenacetin, hydroxyzine and diltiazem were
associated with a higher likelihood of reported adverse effects in drug
consumers ( 2=7.7, P<0.01; 2=4.9, P=0.04; 2=10.6, P<0.01,
respectively). Levamisole, caffeine, procaine and lidocaine were not
associated with an increased likelihood of adverse effects ( 2=3.8, P=0.06;
2=1.1, P=0.3; 2=3, P=0.1, 2=0.1, P=0.8 respectively).
With respect to the nature of different adverse effects reported, cardiac effects (such as chest pain and abnormal heart beat) were associated with
adulterants present in cocaine powders ( 2=10.8, P<0.01). Further analysis
revealed that phenacetin or diltiazem were the two adulterants to cause the
increased likelihood of cardiac effects (see Table 3, 2=7.7, P<0.01;
2=9.3, P<0.01, respectively). Also, hallucinations (often accompanied by
mental disorientation) were reported more often when phenacetin, hydroxyzine or diltiazem were present as an adulterant in cocaine
compared to cocaine without adulterants (see Table 3, 2=4.8, P=0.04;
2=12.0, P=0.02; 2=14.0, P<0.01, respectively).
Discussion
These data suggest that in a majority of instances powder sold as cocaine in The Netherlands does indeed contain cocaine as major component. There was a statistically significant upward trend in the occurrence of adulterated cocaine powders between 1999 and 2007. Cocaine samples adulterated with phenacetin, caffeine, diltiazem and levamisole increased in frequency over this period. A possible explanation for this worrying phenomenon might be that the demand for cocaine has risen in Europe. This is reflected by the increasing amount of cocaine seized by law enforcement agencies during 2000 to 2005 (UNODC; 2007). Furthermore, consumption of cocaine in this period has also increased (UNODC; 2007;
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EMCDDA; 2007). We hypothesize that adulterants are added to meet the increased demand and that they are used as cheaper alternatives to cocaine to increase the profits by diluting the final product. Whereas a number of previous studies have reported all of the main adulterants in cocaine that we detected in this report (McKinney, Postiglione & Herold; 1992; Fucci & De Giovanni; 1998; Kenyon, Ramsey, Lee, Johnston & Holt; 2005; Staack, Paul, Schmid, Roider & Rolf; 2007; Behrman; 2008), to our knowledge, this is the first report of trends over time.
Based on self-report, the analysis in this study suggests that adulterated cocaine is more frequently associated with reported adverse effects than unadulterated cocaine. Phenacetin, hydroxyzine and diltiazem appeared to be three adulterants contributing to these reported adverse effects. Further evaluation of these adulterants requires some reference to their mechanism of action and possible interactions with cocaine. In terms of drug interactions with cocaine very little is known from literature and in most cases evidence is confined to speculation. It is important to note that many of these adulterants are prescribed for oral ingestion in circumstances of medical treatment. In the case of adulterated cocaine they are ingested through other routes, such as intranasally or by inhalation. This may affect pharmacokinetic parameters, such as rate of absorption or bioavailability.
Diltiazem is a calcium channel blocker, and its main mechanism of action and clinical use as an anti-arrhythmic and anti-ischemic has already led it to be investigated in relation with the cardiotoxic properties of cocaine (Schindler, Tella, Erzouki & Goldberg; 1995; Apostolakos; & Varon; 1996). It is possible that the distributors of street cocaine may have actually tried to alter the hazard profile of the drug by trying to attenuate some of the negative cardiac responses to cocaine by adding diltiazem. However, from these studies no consistent protective effect or interaction of diltiazem on cocaine-induced cardiac toxicity is apparent. The data we present actually suggest the contrary, since many of the adverse effects of diltiazem were cardiovascular. Interaction between cocaine and diltiazem is probably complex (Rowbotham, Hooker, Mendelson & Jones; 1987; Ansah, Wade & Shockleu; 1993). The hallucinatory effects experienced by some users may
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be due to secondary events of the cardiac effects (faintness, fatigue). Only limited evidence is available that describes psychoactive phenomena after use of (high doses) diltiazem (Punukollu, Gowda, Khan & Dogan; 2003). It remains to be investigated whether nasal insufflation with diltiazem adulterated cocaine may result in similar systemic doses.
Both the cardiac effects and hallucinations reported in association with phenacetin are difficult to interpret. The carcinogenic risk associated with chronic exposure to high doses of phenacetin has been assessed as at least 0.5 gram of phenacetin a day (Ames, Magaw & Gold; 1987). To reach these doses however, a user would need to consume cocaine well in excess of this amount, at which point direct adverse effects of cocaine would be more likely. No studies have described acute toxicity of phenacetin. Intranasal administration of phenacetin has not been studied however, and there might be some evidence to suggest that this route of administration could play a role in increased toxicity (Ding & Kaminsky; 2003; Peters, Morishima, WArd, Coakley, Kimura & Gonzalez; 1999). Toxicity may be the result of certain toxic metabolites that are formed by enzymes present in the intranasal mucosa (Gu, Cui, Behr, Zhang, Zhang, Yang et al., 2005; Brittebo; 1987; Hinson; 1983). There may also be a possibility of direct interaction of cocaine or one of its metabolites with phenacetin or one of its metabolites, but this is clearly a topic for further research. Although it has been banned from sale in some countries, there is evidence to support that phenacetin is still widely available (McTavish; 2004). Nevertheless, there is uncertainty as to why this substance is used as an adulterant in the illicit drug distribution market.
Hydroxyzine is used both as anxiolytic and antihistamine (Sweetman; 2006). It is a competitive histamine H1-receptor antagonist and causes relief from histaminergic reactions, such as bronchoconstriction. The anxiolytic properties of hydroxyzine are not completely understood (Llorca, Spadone, Sol, Danniau, Bougerol, Corruble et al.; 2002). The hallucinations that were reported in our study are most likely explained by the adverse side-effects of hydroxyzine, such as dizziness and drowsiness (Sweetman; 2006). Nothing is known about intranasal administration of hydroxyzine. Possibly, unpredictable effects of intranasal application could
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play a role in occurring adverse effects. No interactions between hydroxyzine and cocaine are described. However, both are inhibitors of the same cytochrome P450 isoform CYP2D6 (Rendic; 2002). This may result in possible adverse reactions due to decreased detoxification (Miksys & Tyndale; 2004). It is not known why hydroxyzine is used as adulterant, other than to simply cut cocaine and increase profit (Behrman; 2008). Another substance that was added to cocaine was atropine. In certain aspects atropine may exert similar effects on the CNS as cocaine does, but its mechanism of action is different. It inhibits the parasympathic nervous system by antagonizing the muscarinergic acetylcholine receptor system (Geyermek; 1998). Atropine causes symptoms such as increased heart rate, hallucinations, blurred vision, delirium and eventually coma. Cocaine enhances the toxicity of atropine by inhibiting the same receptor mechanism (Sharkey, Ritz, Schenden, Hanson & Kuhar; 1988). Additionally, the sympathicomimetic effects of cocaine are no longer counterbalanced by the parasympathic nervous system and heart rate is disproportionately increased. One might hypothesize that small amounts of atropine are added to “boost” or “mimic” cocaine‟s effects, while actually making a cheaper product.
In interpreting these findings and speculating on possible mechanisms we have to mention some limitations that are a result of the way our data were assembled. First of all, the drug users did not report anything about the dosage of cocaine that was used after experiencing adverse effects or about the circumstances or combinations with medicines, drugs or alcohol at the time they used cocaine. This does not question the fact that there is an obvious difference between unadulterated cocaine and adulterated cocaine, but it does raise questions concerning the exact cause of adverse effects in these instances. Furthermore, most adulterants were not quantified by the laboratory, so it is unknown how much of an adulterant was actually ingested after experiencing certain adverse effects. Another limitation of this study with regard to the trends in cocaine is the fact that these samples may not be entirely representative of the cocaine on the street. A possible bias may occur due to the possibility that testing drug users often have their drugs tested because of specific concern to their
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health (Korf, Benschop & Brunt; 2003). The DIMS might have actually received proportionally more suspicious (diluted) samples as there are circulating on the street.
Despite these possible shortcomings, the present data provide a unique insight into the drug market with regard to individual and public health. Especially for cocaine powders that do not display any recognizable characteristics, it is important to keep track on what is added to them and what the consequences for health might be. Clearly, the increase in adulterated cocaine causes additional concern to the health of (potential) drug consumers. Further risk assessments of adulterated street drugs could serve to keep public and government informed and can be used for drug prevention activities. This information may be vital, as was the case with atropine where mass media warning campaigns were carried out to alert the public. It is this exchange of information where the DIMS system serves as a monitor in order to prevent potentially serious health hazards from escalating.
